High-output fistula

Nutrition Management of the High-Output Fistulae

Enterocutaneous fistulae (ECFs) are commonly encountered complications in medical and surgical practice. High-output fistulae are associated with significant morbidity and mortality, poor quality of life, and a substantial healthcare burden. An interdisciplinary team approach is crucial to prevent and mitigate the adverse clinical consequences of high-output ECFs including sepsis, metabolic derangements, and malnutrition. Patients with ECFs are at a significantly higher risk of developing malnutrition and close monitoring by nutrition support professionals and/or a nutrition support team is an essential component of their medical management. High-output ECFs often require the initiation of nutrition support through either enteral or parenteral routes. Historically, parenteral nutrition (PN) has been the primary method of nutrition support in these patients. However, oral and enteral nutrition (EN) should remain viable options if an evaluation of the location of the ECF, amount of remaining functional bowel, and volume of ECF output identifies favorable conditions. Additionally, in contrast to PN, oral nutrition and EN are the preferred method of feeding because of the maintenance of the structural and functional integrity of the gastrointestinal tract. The inclusion of pharmacological interventions can greatly assist with the reduction and stabilization of ECF output and thereby permit sustained enteral feeding. Initiation of supplemental or full PN will be required if oral nutrition and EN lead to metabolic derangements, fail to meet energy requirements, or do not maintain or improve the patient's nutrition status. The main focus of this review is to discuss the nutrition management of patients with high-output ECFs.

Creativity in Containing a Patient's High-Output Fistula: A Case Report

A gastrogastric fistula is a rare complication of Roux-en-Y gastric bypass resulting from communication between the gastric pouch and gastric remnant. This case report describes the creative interprofessional management of this condition arising in a 48-year-old woman. During an elective Roux-en-Y gastric bypass surgery for morbid obesity, the patient developed respiratory complications. She was admitted to the ICU, but the following day she signed herself out against medical advice, stating she was "no longer staying here." Within 24 hours, she returned to the ED for postoperative complications, and a week after the exploratory surgery, the patient developed an inoperable high-output fistula. The authors devised a creative solution to contain the effluent and achieved closure of the fistula after several weeks.

Patterns of regional variation of opioid prescribing in primary care in England: a retrospective observational study

BACKGROUND

Opioids are a widely prescribed class of drug with potentially harmful short-term and long-term side effects. There are concerns about the amounts of these drugs being prescribed in England given that they are increasingly considered ineffective in the context of long-term non-cancer pain, which is one of the major reasons for their prescription.

AIM

To assess the amount and type of opioids prescribed in primary care in England, and patterns of regional variation in prescribing.

DESIGN AND SETTING

Retrospective observational study using publicly available government data from various sources pertaining to opioids prescribed in primary practice in England and Indices of Social Deprivation.

METHOD

Official government data were analysed for opioid prescriptions from August 2010 to February 2014. The total amount of opioid prescribed was calculated and standardised to allow for geographical comparisons.

RESULTS

The total amount of opioid prescribed, in equivalent milligrams of morphine, increased (r = 0.48) over the study period. More opioids were prescribed in the north than in the south of England (r = 0.66, P<0.0001), and more opioids were prescribed in areas of greater social deprivation (r = 0.56, P<0.0001).

CONCLUSION

Long-term opioid prescribing is increasing despite poor efficacy for non-cancer pain, potential harm, and incompatibility with best practice. Questions of equality of care arise from higher prescription rates in the north of England and in areas of greater social deprivation. A national registry of patients with high opioid use would improve patient safety for this high-risk demographic, as well as provide more focused epidemiological data regarding patterns of prescribing.

Management of Intestinal Failure: The High-Output Enterostomy and Enterocutaneous Fistula

This article provides an overview of the pathophysiology, causes, investigations, and management of high-output enterostomy and enterocutaneous fistula. High-output stoma and enterocutaneous fistula can result in intestinal failure and this is often fatal if not managed properly. The management involves reducing fluid losses, providing nutrients with fluids, and treating the underlying cause and sepsis. A multidisciplinary approach is required for successful management of patients with high-output enterostomy and enterocutaneous fistula.

Effect of Oral ω3-Polyunsaturated Fatty Acids as a Complement Management to Control Fistula Output and Inflammation in Patients With Digestive Fistula

BACKGROUND

The presence of digestive fistula involves chronic inflammation and fibrosis. It has been reported that ω3-polyunsaturated fatty acids stimulate the resolution of inflammation.

AIM

Determine if the administration of oral ω3 reduces fistula output and the time required for fistula closure.

METHODS

Forty-nine patients with postoperative fistula were randomly divided in two groups: 26 received conventional treatment and 23 received the conventional treatment supplemented with ω3 (540 mg eicosapentaenoic acid and 360 mg docosahexaenoic acid) for 35 days. Patients were monitored daily for fistula output and spontaneous closure. Additionally, serum pro-inflammatory cytokines and C-reactive protein were quantified in four patients with conventional and in seven patients with ω3 treatment.

RESULTS

Patients with ω3 had significantly decreased fistula output from days 2 to 27, compared to control (p < 0.05). Spontaneous fistula closure was achieved in 15 patients (65%) in the ω3 group and in 14 (54%) in the control group. ω3-polyunsaturated fatty intake also decreased the serum concentrations of interleukin-6 and C-reactive protein (p < 0.05).

CONCLUSIONS

Our results suggest that ω3 supplementation to conventional medical treatment decreases fistula output and reduces inflammation (interleukin-6 and C-reactive protein), and these effects may increase the efficiency of conventional medical treatment.

Metabolic and nutritional support of the enterocutaneous fistula patient: a three-phase approach

BACKGROUND

The care and outcome of enterocutaneous fistula (ECF) have improved greatly over several decades due to revolutionary advances in nutrition, along with dramatic improvements in the treatment of sepsis and the critically ill. However, as the collective experience with damage control surgery has matured, the frequent development of enteroatmospheric fistula (EAF) in the "open abdomen" patient has emerged as an even more vexing problem. Despite our best efforts, ECF and especially EAF continue to be highly morbid conditions, and sepsis and malnutrition remain the leading causes of death. Aggressive nutritional and metabolic support is the most significant predictor of outcome with ECF and EAF.

RESULTS

Discussion of the historical advances in nutritional therapy and their impact on ECF, as well as review of the classification of ECF and EAF, provides a framework for the suggested phased strategy that specifically targets the nutritional and metabolic needs of the ECF/EAF patient. These three phases include (1) diagnosis, resuscitation, and early interval nutrition; (2) definition of fistula anatomy, drainage of collections, nutritional assessment and monitoring, and placement of feeding access; and (3) definitive nutritional management, including pharmacologic adjuncts. Early nutritional support with parenteral nutrition followed by transition to enteral nutrition is advocated, including the merits of delivery of enteral nutrition via the fistula itself, known as fistuloclysis.

CONCLUSION

Aggressive nutritional therapy is necessary to reverse the catabolic state associated with ECF/EAF patients. Once established, it allows proper time, preparation, and planning for definitive management of the fistula, and in many cases provides the support for spontaneous closure.

Historical perspectives in the care of patients with enterocutaneous fistula

Evidence can be found throughout surgical history of how devastating an enterocutaneous fistula (ECF) can be for both patient and surgeon. From antiquity, this complication of abdominal surgery, malignancy, radiation, trauma, or inflammatory processes has been a significant challenge to surgeons due to high associated mortality and significant morbidity. An ECF causes dehydration, malnutrition, skin excoriation, and sepsis, and has profound psychological effects on the patient. Recent mortality rates of patients suffering an ECF approach 20%. The authors illustrate the history of management of patients with ECF and discuss advances in perioperative care including parasurgical care, nutrition, wound care, and the history of surgical techniques.

Successful bridging treatment and healing of enteric fistulae by vacuum-assisted closure (VAC) therapy and targeted drainage in patients with open abdomen

PURPOSE

The object of this study was to investigate the bridging treatment of enteric fistulae by vacuum-assisted closure (VAC) therapy in patients with open abdomen.

METHODS

We retrospectively analyzed patients who have been treated between 1 January 2007 and 31 December 2008 at the intensive care unit of the Department of General Surgery, Medical University Vienna. Control of the fistula was established by VAC therapy to bridge the patients to the time of the fistula resection.

RESULTS

In the period of investigation, we treated nine (six men/three women) patients suffering from enteric fistulae with VAC therapy. The median age of the patients was 48 (range, 37-67) years. The median duration of VAC therapy was 76 (range, 53-128) days. The median length of stay in the intensive care unit was 44 (range, 25-127) days. The median APACHE II score was 23 (range, 18-25). The predicted mortality was 40%; the actual mortality was 11% (one patient). Primary fascial closure was achieved after median 91 (range, 89-92) days in three patients (33%) and secondary fascial closure after median 292 (range, 252-546) days in another three patients (33%). Fistulae were cured with VAC (five patients, 56%) and surgical resection (three patients, 33%). None of the patients developed a refistulation at the time of follow-up.

CONCLUSIONS

Control of enteric fistulae by VAC therapy can lead to spontaneous fistula closure and is associated with a low mortality.

Postoperative enterocutaneous fistula: when to reoperate and how to succeed

An enterocutaneous fistula (ECF) is a potentially catastrophic postoperative complication. Although the morbidity and mortality associated with ECF have decreased over the past 50 years with modern medical and surgical care, the overall mortality is still surprisingly high, up to 39% in recent literature. It seems prudent, then, for every surgeon to have a thorough grasp of optimal treatment strategies for ECF to minimize their patients' mortality. Ultimately, the algorithm must begin with prevention. Once an ECF is diagnosed, the first step is to resuscitate and treat sepsis. The second is to control fistula output. The third step is to optimize the patient medically and nutritionally. The last step is definitive restoration of gastrointestinal continuity when necessary. Special mention is given in this article to exceptionally refractory fistulas such as those arising in the presence of inflammatory bowel disease and irradiated bowel. This plan gives a framework for the difficult task of successfully treating the postoperative ECF with a multidisciplinary approach.